HospitalInspections.org

Based on record reviews and interviews, the Governing Body failed to ensure contracted dialysis services were provided in a safe manner for all Hemodialysis patients. The facility failed to:

1.) Ensure dialysis nursing staff practiced established infection control measures by appropriately applying and/or removing Personal Protective Equipment (PPE) when working in isolation rooms, for 3 of 3 isolation patient (#30) who recieved dialysis treatments, and;


2.) Ensure dialysis nursing staff disinfected dialysis machines and portable Reverse Osmosis (RO) water units before removing them from isolation rooms, as well as disposing of and/or disinfecting supplies and equipment, for 1 of 3 isolation patients (#30) who received dialysis treatments, and;

This deficient practice placed all patients receiving treatment in the facility at an increased risk of life threatening infections, leading up to and including the possibility of death.


Refer to tag: A-0083

Based on record reviews and interviews, the Governing Body failed to ensure contracted dialysis services were provided in a safe manner for all Hemodialysis patients. The facility failed to:

1.) Ensure dialysis nursing staff practiced established infection control measures by appropriately applying and/or removing Personal Protective Equipment (PPE) when working in isolation rooms, for 3 of 3 isolation patient () who recieved dialysis treatments, and;


2.) Ensure dialysis nursing staff disinfected dialysis machines and portable Reverse Osmosis (RO) water units before removing them from isolation rooms, as well as disposing of and/or disinfecting supplies and equipment, for 1 of 3 isolation patients (#) who received dialysis treatments, and;

This deficient practice placed all patients receiving treatment in the facility at an increased risk of life threatening infections, leading up to and including the possibility of death.

Findings include:

1.) Record review of the clinical record for Patient #30 revealed that he was a 46 year old male with a history of End Stage Renal Disease (ESRD), hypertension, and Diabetes type II. Further review revealed he was on contact isolation precautions for Methicillin Resistant Staphylococcus Aureus (MRSA) of the wound on his left lower extremity, and was actively receiving hemodialysis treatment at the bedside. Further observations revealed the following:

- Observations conducted on 7/30/18 at 1: 35 pm revealed the following:

-Staff RN 51 was observed in Patient #30's isolation room touching the bedisde computer cart (WOW Cart) without changing/ removing her gloves, she then placed a gloved hand underneath her protective gown touching her personal sethoscope, trying to untangle the sethoscope from her scrub top. RN-B then exited the patient room without disinfecting the sethoscope or WOW cart and entered the next patient room immediately afterwards.

In an interview conducted on 7/30/18 at the time of observation, nursing administrative staff confirmed the above findings, and stated that nursing staff are not to bring non-disposable items inside isolation rooms, and that medical equipment is to be disinfected per policy beofre use in another patient room.


2.) Observations conducted on 7/30/18 at 1:25 pm revealed the following:

-A portable Reverse Osmosis (RO) system used by the dialysis department was left unattended in the patient care hallway which was readily accessible to visitors, patients and staff. The RO machine was visibly soiled with a white and yellow substance, and contained disposable chlorine test strips, a plastic graduated cup, and a paper binder on top of the machine.

- In an interview conducted on 7/30/18 at 1:35 pm, Dialysis Registered Nurse (RN) #1 revealed that the RO machine viewed by the surveyors in the hallway had just been used in Patient# 30's isolation room, to include the supplies and manual on top of the machine.

- During further observations conducted on 7/30/18 at 2:35 pm the RO machine in questions was observed in the dialysis storage room where clean supplies were kept. The machine was still visibly soiled with the white and yellow substances and contained the cup, test strips, and paper manual located on the top of the machine which was in use in the isolation room.

- In an interview conducted on 7/30/18 at the time of discovery, nursing administrative staff confirmed the above findings.

Record review of the facility policy entitled: MRSA Precautions, approved 1/2018 revealed in part the following:
Procedures: Section A:
Isolation Precautions for MRSA:
- Patient care equipment- dedicate the use of noncritical patient-care equipment to a single patient if feasible. If common equipment is used, clean and disinfect between patients.

Facility policy entitled: Disinfection and Sterilization plan for Medical Equipment, Devices, Supplies, and Direct Patient Environment, Approved 2/2018, Revealed in part the following:

B.) Cleaning of patient care devices
- If patient is in Contact Precautions the equipment needs to be wiped down with PDI Super Sani-Cloth (Purple Top) wipes whenever feasible or by approved manufacturer recommendations. If in Contact Precautions Enhanced, after the equipment id also cleaned with bleach wipes.
- Place equipment in designated area (if not cleaned/ disinfected and staying in room.)
- If equipment is contaminated with blood that cannot be cleaned by staff; place it in a dark grey bag and place a clearly visible biohazard sticker on the bag.


Information from Quality and Patient Safety Committee Medical Center Minutes, dated February 20, 2018, revealed in part the following:

Under Dialysis:
Provide review of data from our dialysis provider.....This month an outside auditor was used and it was noted that cleaning and disinfection of the dialysis station needed to be performed. The second area of opportunity is sing hand sanitizer before you put on your gloves and using hand sanitizer between procedures. This was addressed immediately.

Recommendation: Information

Follow-up: none

Based upon observation, record review, and interview, the facility failed to ensure evidence that 10 of 10 patients reviewed for patient rights (Patient's #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10); were informed of their patient rights orally and in writing, in advance of furnishing patient care, and prior to discharge. Specifically,

Patient's #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 medical records did not contain a signed copy of their patient rights or evidence they were informed of their patient rights.

Findings included:

Review of the facility's Patient Rights and Responsibilities policy in part, last revised 04/17 revealed the patient or the patient's surrogate decision-maker will be informed of the "Patient's Rights & Responsibilities" at the time of admission by the Patient Access Representative (PAR). If requested, the PAR will provide the patient a copy of the Patient's Rights & Responsibility.

Observation conducted in Facility B on 7/31/18 at 09:25 AM of the Emergency Department (ED) revealed Registration Clerk #1 was completing the admission/registration process inside of ED Room #5 for Patient #8. There was not any discussion regarding Patient's rights. There was not a signature obtained from Patient #8 regarding her patient rights, or a copy of the patient rights provided to Patient #8. Observation consisted of the Registration Clerk #1 reviewing and summarized the Hospital Care Consent to Patient #8 by stating it was a consent for treatment, acknowledgement of receipt for Privacy Practices, and indication that her insurance was in network. The Registration Clerk then requested Patient #8 to sign acknowledgment this information was discussed.

Record review of Patient's #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 medical records revealed there was no evidence or documentation that Patients signed a copy of their patient rights, were given a copy of the Patient Rights, or were informed of their Patient's Rights either orally and/or in writing. The medical records contained a form; "Hospital Care Consent" that indicated the following:
4. Patient Rights and Advance Directives: The Facility provided me a copy of the Patient Rights and Responsibilities when I arrived to the hospital. I also understand that I can request a copy any time.
Further review of the Hospital Care Consent on page 3 had a patient signature for Acknowledgement that certified by signature that the patient read the document, understand its contents, and agree to the terms.

During an interview on 7/31/18 at 09:30 AM with the Registration Clerk #1 stated during registration for admission that patients were to be offered a copy of the "notice of privacy practices" if requested by the patient. Registration Clerk #1 stated she would have patients sign the hospital care consent, but did not have patients sign a copy of the patient rights and responsibilities. Registration Clerk #1 stated she could print the patient rights and responsibilities if needed from the patient record and present it to the patient if requested, or after she verified insurance; and only if she needed to go back to talk to the patient regarding insurance verification; then she would take a copy of the patient rights in case the patient had a question.

Record review of Patient #8's medical record dated 7/31/18 revealed a document titled patient rights and responsibilities. The Patient Rights and Responsibilities had not been signed by Patient #8. This document was not presented to Patient #8 during the time of admission by the PAR/Registration Clerk #1 during observation on 7/31/18 at 09:25 AM.

During an interview on 08/1/18 at 09:30 AM with the Director of Quality stated the facility used the same admission forms for all of their facilities (19) under this license number. The Director of Quality confirmed the sampled records reviewed for those inpatient admissions did not include a signed copy by the patient of their patient rights.

29242




Based on observations, interviews, and records review, the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. The facility failed to:


1.) Ensure dialysis nursing staff practiced established infection control measures by appropriately applying and/or removing Personal Protective Equipment (PPE) when working in isolation rooms, for 3 of 3 isolation patient (#30) who recieved dialysis treatments, and;


2.) Ensure dialysis nursing staff disinfected dialysis machines and portable Reverse Osmosis (RO) water units before removing them from isolation rooms, as well as disposing of and/or disinfecting supplies and equipment, for 1 of 3 isolation patients (#30) who received dialysis treatments, and;


3.) Ensure the operating rooms and wound care areas were kept clean and free from potential infection, i.e. dirt, rust, and bological debris.

This deficient practice placed all patients receiving treatment in the facility at an increased risk of life threatening infections, leading up to and including the possibility of death.


Refer to tag: A-0749


34617

Based on observations, interviews, and records review, the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. The facility failed to:


1.) Ensure dialysis nursing staff practiced established infection control measures by appropriately applying and/or removing Personal Protective Equipment (PPE) when working in isolation rooms, for 3 of 3 isolation patient (#30) who recieved dialysis treatments, and;


2.) Ensure dialysis nursing staff disinfected dialysis machines and portable Reverse Osmosis (RO) water units before removing them from isolation rooms, as well as disposing of and/or disinfecting supplies and equipment, for 1 of 3 isolation patients (#30) who received dialysis treatments, and;


3.) Ensure the operating rooms and wound care areas were kept clean and free from potential infection, i.e. dirt, rust, and bological debris.

This deficient practice placed all patients receiving treatment in the facility at an increased risk of life threatening infections, leading up to and including the possibility of death.

Findings include:

1.) Record review of the clinical record for Patient #30 revealed that he was a 46 year old male with a history of End Stage Renal Disease (ESRD), hypertension, and Diabetes type II. Further review revealed he was on contact isolation precautions for Methicillin Resistant Staphylococcus Aureus (MRSA) of the wound on his left lower extremity, and was actively receiving hemodialysis treatment at the bedside. Further observations revealed the following:

- Observations conducted on 7/30/18 at 1: 35 pm revealed the following:

-Staff RN-B was observed In patient #30's isolation room touching the bedisde computer cart (WOW Cart) without changing/ removing her gloves, she then placed a gloved hand underneath her protective gown touching her personal sethoscope, trying to untangle the sethoscope from her scrub top. RN-B then exited the patient room without disinfecting the sethoscope or WOW cart and entered the next patient room immediately afterwards.

In an interview conducted on 7/30/18 at the time of observation, nursing administrative staff confirmed the above findings, and stated that nursing staff are not to bring non-disposable items inside isolation rooms, and that medical equipment is to be disinfected per policy beofre use in another patient room.


2.) Observations conducted on 7/30/18 at 1:25 pm revealed the following:

-A portable Reverse Osmosis (RO) system used by the dialysis department was left unattended in the patient care hallway which was readily accessible to visitors, patients and staff. The RO machine was visibly soiled with a white and yellow substance, and contained disposable chlorine test strips, a plastic graduated cup, and a paper binder on top of the machine.

- In an interview conducted on 7/30/18 at 1:35 pm, Dialysis Registered Nurse (RN) #1 revealed that the RO machine viewed by the surveyors in the hallway had just been used in Patient#30's isolation room, to include the supplies and manual on top of the machine.

- During further observations conducted on 7/30/18 at 2:35 pm the RO machine in questions was observed in the dialysis storage room where clean supplies were kept. The machine was still visibly soiled with the white and yellow substances and contained the cup, test strips, and paper manual located on the top of the machine which was in use in the isolation room.

- In an interview conducted on 7/30/18 at the time of discovery, nursing administrative staff confirmed the above findings.

Record review of the facility policy entitled: MRSA Precautions, approved 1/2018 revealed in part the following:
Procedures: Section A:
Isolation Precautions for MRSA:
- Patient care equipment- dedicate the use of noncritical patient-care equipment to a single patient if feasible. If common equipment is used, clean and disinfect between patients.

Facility policy entitled: Disinfection and Sterilization plan for Medical Equipment, Devices, Supplies, and Direct Patient Environment, Approved 2/2018, Revealed in part the following:

B.) Cleaning of patient care devices
- If patient is in Contact Precautions the equipment needs to be wiped down with PDI Super Sani-Cloth (Purple Top) wipes whenever feasible or by approved manufacturer recommendations. If in Contact Precautions Enhanced, after the equipment id also cleaned with bleach wipes.
- Place equipment in designated area (if not cleaned/ disinfected and staying in room.)
- If equipment is contaminated with blood that cannot be cleaned by staff; place it in a dark grey bag and place a clearly visible biohazard sticker on the bag.

3.) During a tour of the preoperative nurses station at the Medical Center campus on 07/30/18 at 1:30 p.m. accompanied by S#1, S#2 and S#3 observation revealed the following:

Separation of the caulking around the sink and backsplash such that the area could not be properly cleaned.

Brownish discoloration of caulking at the back of the sink.

An ice machine with a thick buildup of white debris on the grate and tray below.

In an interview of S#1 on 07/30/18 at 1:30 p.m. in the medication room, S#1 confirmed the above findings.

During a tour of the cysto room at the Medical Center campus on 07/30/18 at 1:48 p.m. accompanied by S#1, S#2, and #3 observation revealed rust to a bipolar stand such that it could not be properly cleaned.

In an interview of S#1 on 07/30/18 at 1:48 p.m. in the medication room, S#1 confirmed the above findings.

During a tour of the medication room for the operating rooms at the Medical Center campus on 07/30/18 at 2:20 p.m. accompanied by S#1 and S#2, observation revealed the following:

Dusty debris along all the base of the baseboards.

Dusty debris, a piece of used tape, and an opened empty medication ampule on the floor behind the door.

Black debris on top of a fluid warmer.

Dried drippage on the inside of the glass door of the pyxis unit and dried debris in the corners of the bottom shelf of the unit.

In an interview of S#1 on 07/30/18 at 2:30 p.m. in the medication room, S#1 confirmed the above findings.

During a tour of the post anesthesia care unit at the Medical Center campus on 07/30/17 at 2:45 p.m. accompanied by S#1 and S#2, observation of the ice machine revealed a buildup of white debris on the grate with white and pinkish brown debris in the tray below the grate.

In an interview of S#1 on 07/30/18 at 2:45 p.m. in front of the ice machine in the post anesthesia care unit, S#1 confirmed the above findings.

During a tour of the Wound Care and Hyperbaric Center on 08/01/18 beginning at 9:40 a.m. accompanied by S#1 and CWCS#1 observation revealed the following:

On 08/01/18 at 9:55 a.m. in front of the pyxis at the Wound Care Center across from the Medical Center campus, CWCS#2 placed a 6" ace bandage in a clear wrapper under her left armpit.

In an interview of S#1 on 08/01/18 at 9:56 a.m. near the pyxis unit at the Wound Care Center across from the Medical Center campus, S#1 confirmed the above findings.

During a tour of the Hyperbaric area of the Wound Care and Hyperbaric Center across from the Medical Center campus on 08/01/18 at 10:05 a.m. accompanied by S#1 and CWCS#1 inspection and observation of the dressing cart revealed the following:

Dusty and sticky debris on top of the cart that could be manually removed.

A recessed bin in the back of the top of the cart with dusty debris and a bit of paper that contained a pair of plastic glasses.

Dusty debris outside and inside drawers that contained items for patient use.

Dusty debris to a recessed opening to the left side of the cart.

A thick layer of dust to the ledge on the left bottom side of the cart such that the dust could be wiped up into a ball.

Dirty debris to the front bottom shelf.

A drawer that contained one (1) tube of silvasorb gel that "EXP06/2018," and two (2) tubes of silvasorb gel that "EXP07/2018."

In an interview of S#1 on 08/01/18 at 10:20 a.m. in the Wound Care Center across from the Medical Center campus, S#1 confirmed the above findings.

The Hoshizaki America, Inc. Cubelet Icemaker/Dispenser Service Manual provided and identified by S#2 on 07/31/18 as the service manual for the icemaker in the pre-op area and in the post anesthesia care unit at Christus Santa Rosa Medical Center was reviewed on 07/31/18 at 1:15 p.m. in the conference room at the Alamo Heights campus and stated the following in part:

2. CLEANING INSTRUCTIONS

WARNING
1. HOSHIZAKI recommends cleaning this unit at least twice a year. More frequent cleaning, however, may be required in some existing water conditions.

[a] CLEANING PROCEDURE

2. Dilute approximately 6 fl. Oz. of recommended cleaner Hoshizaki "Scale Away" or "LIME AWAY" (manufactured by Economics Laboratory, Inc.) with 1 gal. of water.

A hospital document entitled, "EOC, Cleaning & Disinfection Responsibilities," with a revised date of "5/2018," provided by S#2 on 07/31/18 was reviewed on 07/31/18 at 1:45 p.m. in the conference room at the Alamo Heights campus and stated the following in part:

HHS - Environmental Services

" Ice Machines all external surfaces, including water trap tray; place maintenance work order (WO) if scale or damage makes it no longer cleanable
" Reports rusted equipment to dept. leader (bedside commodes, OR tables, etc.)
" Pharmacy Pyxis machines - clean behind weekly; (Pharmacy cleans inside and users clean surfaces)

A hospital policy entitled, "CO-ICP-05-01 Disinfection and Sterilization Plan for Medical Equipment, Devices, Supplies, and Direct Patient Environment," with a last approved date of "February 2018," was reviewed on 07/31/18 at 2:00 p.m. in the conference room at the Alamo Heights campus and stated the following in part:

PROCEDURE:
E. Cleaning and Disinfecting Environmental Surfaces in Healthcare Facilities
1. Clean housekeeping surfaces (e.g., floors, tabletops) on a regular bases, when spills occur, and when these surfaces are visibly soiled.
2. Disinfect (or clean) environmental surfaces on a regular basis (e.g. daily when in use) and when surfaces are visibly soiled.
10. Wet-dust horizontal surfaces regularly (e.g. daily) using clean cloths moistened with an EPA-registered hospital disinfectant (or detergent).

A hospital document entitled, "ENVIRONMENTAL SERVICES," provided by S#2 on 07/31/18 was reviewed on 07/31/18 at 2:20 p.m. in - the conference room at the Alamo Heights campus and stated the following in part:

Floor Tech Position Goal - Our goal is to provide a superior level of cleaning quality in an assigned area to maintain a clean working environment.

Floor Care Tasks
Sweep & Mop Tile Floors (m)
Dust/damp mop
Spot clean baseboards

Ancillary Areas
Clean Daily
Dust & mop tile floors

Detail Weekly (as scheduled)
Baseboards & corners

In an interview of S#2 on 07/31/18 at 2:15 p.m. in the conference room at the Alamo Heights campus, S#2 confirmed that the medication room in the operating suite would be considered an ancillary area.

In an interview of S#18 on 08/01/18 at 2:55 p.m. in the conference room at Christus Santa Rosa Medical Center, S#18 provided a copy of a Tracer Observation Detail Report One Path Partners Tracer for the Wound Care Center at the Westover Hills campus dated 06/28/2018 that includes question #13 "Are all areas clean?" But S#18 did not provide a Tracer Observation Detail Report for the Wound Care and Hyperbaric Center and S#18 stated, "They are not doing the audit at the Medical Center Wound Care Center."

Based on observation, interview and policy review the hospital failed to meet the requirement to implement and enforce its policy on packaging of instruments for sterilization because instruments in peel pouches andr wrapped items lacked a load label, did not include a description, and/or did not include the initials of the package assembler and instruments with unprotected sharp tips were packaged in peel pouches such that the integrity of the packaging could be breached and were available for patient use.

Findings Include:

During a tour of the sterile instrument room at the Medical Center campus on 07/30/18 at 2:00 p.m. accompanied by S#1, S#2, and S#5 observation revealed the following:

Two (2) key elevators in peel pouches without a load label and that lacked the initials of the package assembler.

One (1) key elevator in a peel pouch that lacked the initials of the package assembler.

Eight (8) peel pouches that did not include a description and lacked the initials of the package assembler. Seven (7) of these peel pouches contained instruments with unprotected sharp tips.

In an interview of S#5 in the sterile instrument room on 07/30/18 at 2:00 p.m., S#5 confirmed the above findings.

During a tour of the sterile instrument room at the Alamo Heights campus on 07/31/18 at 11:00 a.m. accompanied by S#2, S#11 and S#14 observation revealed the following:

Peel pouches and wrapped items lacked the initials of the package assembler. An example of some of the peel pouches inspected that did not include the initials of the package assembler include a mono cord, a micro mosquito, a pair of dressing forceps and an item that did not include a description but looked like a condom. An example of wrapped items inspected that did not include the initials of the package assembler include a blue cobb elevator, osteotomes, laparscopic instruments, a small joint shaver, and a wrapped item that did not include a description but was identified by S#14 as towels.

In an interview of S#14 in the sterile instrument room on 07/31/18 at 11:00 a.m., S#14 confirmed the above findings and acknowledged they were not labeling any of the peel pouches or wrapped items with the initials of the package assembler.

The hospital policy entitled, "CO-NU-10-97, SUBJECT: Selection and Use of Packing Systems," with an effective date of "06/16," was reviewed on 07/31/18 at 1:35 p.m. in the conference room at the Alamo Heights campus and stated the following in part:

POLICY

Packing systems should ensure sterility of package contents until opened for use...

PROCEDURES

G. Packages to be sterilized should be labeled according to the policies and procedures of the practice setting and according to manufacturers' instructions.

1. Packaging systems should be labeled before sterilization. The label information should include, but not limited to,
a. a description of package contents,
b. initials of the package assembler, and
c. a lot control number